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J E H idi h MD FAAPJeana E. Havidich, MD, FAAP
Disclosures
U f l I h Unfortunately, I have none
Jeana Havidich MD
Goals Discuss current pediatric sedation trendsP i f i di i d i bli h d Present information on pediatric sedation published in non‐anesthesia journalsP id l f d i d l Provide examples of sedation models
Discuss credentialing requirements for sedation idproviders
Discuss role of Anesthesiologists in providing d dpediatric sedation
Demand for Pediatric SedationDemand for Pediatric Sedation Services
Demand for Pediatric SedationDemand for Pediatric Sedation Services Over the past decade, the demand for pediatric sedation has dramatically increased Concept that children experience anxiety and pain Advances in technology Increase in the number of Non‐Operating Room procedures (formerly performed in OR)
Economics Parental, Patient, and Health Care Provider Expectations
What the Literature Reveals inWhat the Literature Reveals in 2009 Literature Search: PEDIATRIC SEDATION
6 Cit ti 14, 967 Citations 13,344 Journal articles
T B k 1771 Text Books 106 Reference Works
Downloaded from www.Sciencedirect.com March 2009
Number of Publications withNumber of Publications with “Pediatric Sedation” 2000‐2009
1200
1400
8
1000
600
800
200
400
0
000
2001
2002
2003
2004
2005
006
2007
2008 00
9
2 2 2 2 2 2 2 2 2 2
Top Ten Journals in 2000Top Ten Journals in 2000 Clinical Pediatric Emergency Medicine (22)g y ( ) International Journal of Pediatric Otorhinolaryngology (14) Annals of Emergency Medicine (12)Annals of Emergency Medicine (12) Pediatric Clinics of North America (11) Anesthesiology Clinics of North America (9)Anesthesiology Clinics of North America (9) Emergency Medicine Clinics of North America (9) The Annals of Thoracic Surgery (8) The Annals of Thoracic Surgery (8) Critical Care Clinics (7) Emergency Procedures for the Small Animal Veterinarian Emergency Procedures for the Small Animal Veterinarian (7)
Seminars in Anesthesia and Perioperative Medicine (7)Seminars in Anesthesia and Perioperative Medicine (7)
Top Ten Journals 2009Top Ten Journals 2009 Journal of Pediatric Surgery (960) Journal of Pediatrics (545) Annals of Emergency Medicine (478)g y Gastrointestinal Endoscopy (458) International Journal of Pediatric Otorhinolaryngology J y g gy(232)
Journal of Oral and Maxillofacial surgery (227) The American Journal of Cardiology (206) Journal of Clinical Anesthesia (197) The American Journal of Emergency Medicine (193) Pediatric Neurology (193)gy 93 American Operating Room Nurses (190)
P bli ti b S i ltPublications by Specialty2000 vs 20092000 vs. 2009
Who Will Provide Sedation? Anesthesiology department is unable or
illi t id d ti i f ll unwilling to provide sedation services for all children Manpower Reluctance to provide sedation or anesthesia outside of the operating room
Not economically feasibley Risk
Are Anesthesia Providers Really Necessary? Are Anesthesia Providers Really Necessary?
Expectations of HospitalExpectations of Hospital Administration
Provision of Excellent Patient Care Provision of Excellent Patient Care High Patient and Parent Satisfaction E i ll S d Economically Sound Good Public Relations Patient Safety
Published SafetyPublished Safety Retrospective Analysisp y QA data collected 23 months prior to and after pimplementation of PSS (5444)
Decreased failed sedations rates: 2.7% to 0.8%
Decreased Cancellation rates 8% 6%3.8% to 0.6%
Decreased hypoxia 8.8% to 6%4.6%
Decreased GETA cases 7.5% to 4 4%to 4.4%Society for Academic Emergency
Medicine 2006
Anesthesiologists, Emergency Room Physicians, g , g y y ,Critical Care specialists, Pediatricians, Sedation Nurses
Total records submitted: 30, 037 Complication rate: 5.3%Complication rate: 5.3%
Serious adverse events were rare No deathsNo deaths One cardiac arrest
In highly motivated and organized sedation services, g y g ,the adverse event rate is relatively low
P di t i S d ti M d lPediatric Sedation Models
Anesthesia Provider/Care Team Pediatric Emergency Medicine Pediatric Emergency Medicine HospitalistsP di t i i Pediatricians
Pediatric Intensivists Advanced Practice Nurses Specialist performing procedure and Sedation Nurse
Sedation Model: AnesthesiologySedation Model: Anesthesiology Anesthesiologist or Anesthesia Care Teamg Advantage: We do it all
Diagnostic and Therapeutic ProceduresDiagnostic and Therapeutic Procedures Efficiency SafetySafety Low Procedural Failure Rate
Disadvantage Disadvantage Expensive Availability Availability
Manpower Co‐ordination with multiple servicesCo ordination with multiple services
Observational study 8760 sedationsT A h i l i d PICU Team: Anesthesiologists and PICU nurses
Children were triaged PICU nurse would sedate children with oral chloral hydrate (1769)
Pediatric Anesthesiologist was immediately available Nurse administered sedation failure rate was 6.5% Adverse event rate 1.7%
The Journal of Pediatrics July 2004
Pediatric Critical Care Rainbow Babies and Children’s Hospital Cleveland, OhioOhio Free Standing Pediatric Sedation Unit (PSU)S ff P di i C i i l C EM h i i d Staff: Pediatric Critical Care, EM physician and one HospitalistP f i l i i d Performs approximately 3000 in‐patient and outpatient sedations per yearM di i d Medications used Midazolam P f l Propofol Dexmedetomidine Ketamine Etomidate Personal
Communication
Pediatric Critical CareRainbow Babies and Children’s Hospital Cleveland, Ohio
Hospital Credentialing Requirements ll d l d f d
Cleveland, Ohio
Intensivists are automatically credentialed for deep sedationOth R i d di ith i ti Others: Required reading with examination Developed by the Department of Anesthesiology
Perform 10 sedations under the supervision of an Perform 10 sedations under the supervision of an Anesthesiologist or Physician who is credentialed to provide deep sedationp ov de deep sedat o
Must perform a minimum of 10 sedations per year
P lPersonal Communication
Pediatric Critical CareRainbow Babies and Children’s Hospital Cleveland, OhioCleveland, Ohio Referral to Department of Anesthesiology
M t ASA PS III d ll ASA PS IV t Most ASA PS III and all ASA PS IV or greater Obese children (> 150th percentile)S URI Severe URI
Obstructive Sleep ApneaP l H i Pulmonary Hypertension
Severe Cardiac disease Successful working relationship with the Anesthesiology Department Personal
Communication
Pediatric Emergency Medicineg yPediatric Emergency Medicine Associates LLC, Atlanta GeorgiaGeorgia
Primary sedation providers for approximately 7000 cases per yearcases per year
Cases outside of the OR requiring moderate or deep sedationsedation
Medications administeredP f l ( i ) Propofol (primary)
Ketofol (Ketamine and Propofol)( d l ) Ketamine (used less now)
Fentanyl Nitrous oxide Personal Communication
Pediatric Emergency Medicine g yPediatric Emergency Medicine Associates LLC, Atlanta GeorgiaGeorgia
CredentialingPh i i t b B d Eli ibl C tifi d i Physicians must be Board Eligible or Certified in Pediatric Emergency Medicine
Required to attend Airway Course or Required to attend Airway Course or One day in the OR with an Anesthesiologist Review a Sedation Module Review a Sedation Module
Monitor the progress of newly hired physicians on their Sedation service their Sedation service
Personal Communication
HospitalistsChildren’s Hospital of PhiladelphiaChildren s Hospital of Philadelphia
Sedation service is composed of pediatricians, p p ,advanced practice nurses, and sedation nurses (RNs)
Physician or Physician‐nurse team provides sedation Physician or Physician nurse team provides sedation (depending on what level is required) 10 physicians (6.5 FTEs)p y ( 5 ) 25‐30 Registered nurses
Perform approximately 8500 sedations per yearPerform approximately 8500 sedations per year
Personal Communication
HospitalistsHospitalistsChildren’s Hospital of PhiladelphiaChildren s Hospital of Philadelphia
Credentialing Requirements Credentialing Requirements Credentialing course created in conjunction with the Department of AnesthesiologyDepartment of Anesthesiology Hospitalist spend 10 days in the ORThree weeks on sedation service observing Three weeks on sedation service observing experienced sedationist
PALS and ACLS certified PALS and ACLS certified Complete a didactic curriculum
Personal Communication
H it li tHospitalistsChildren’s Hospital of PhiladelphiaChildren s Hospital of Philadelphia Patient Selection
O t ti t h t i Outpatient: phone triage Majority of Patients: ASA PS I or IIR f l h D f A h i l Referrals to the Department of Anesthesiology ASA PS III or greater Congenital Heart Disease Severe Respiratory Disease Syndromes
Personal Communication
PediatriciansLos Angeles Children’s HospitalLos Angeles Children s Hospital
Pediatricians trained in EM or Critical Care perform 2000‐3000 sedations per year 2000 3000 sedations per year A NP screens patients to determine ASA PS Sedations by pediatricians are limited to ASA PS I and II y ppatients for radiological procedures
Practice under the auspices of the Department of Anesthesia QAM bidi d M li C f Morbidity and Mortality Conference
P l C i tiPersonal Communication
PediatriciansLos Angeles Children’s HospitalMedications:Medications: Premedicate with midazolam when required PropofolPropofol Ketamine Not credentialed to use combination of drugsNot credentialed to use combination of drugs
Credentialing Total of 40 hours of trainingTotal of 40 hours of training 20 hours of didactics 20 hours of preceptorship with 20 hours of preceptorship with anesthesiologist or credentialed sedationist
Model has been in existence for 8 yearsy No critical events
Successful Sedation Service Good working relationship with the Department of AnesthesiologyAnesthesiology
Development of GuidelinesEd i l S Educational Support
Development of Hospital Standards for the care of hild i i d d ichildren receiving deep sedation
Open forum and dialogue with the Department of h lAnesthesiology
Comparing and ContrastingComparing and Contrasting Models Similarities
Hi hl ti t d Differences
F St di Highly motivated organized sedation teams
Free Standing vs. Members of the Anesthesia Departmentteams
Collaborated with Department of
Anesthesia Department Credentialing requirementsp
Anesthesia Triage system
q Educational Background
Drug Administration Documentation of continued practice
What’s happening in the AdultWhat s happening in the Adult world? Sedation Model: Physician providing the service will medically direct the sedation nurse (RN) during the medically direct the sedation nurse (RN) during the administration of sedatives and/or analgesics for deep sedationsedation
Propofol Ketamine Ketamine Methohexital
b f (f l) d l Combination of narcotic (fentanyl) and anxiolytic (midazolam)
The American Journal of Gastroenterology 2003The American Journal of Gastroenterology 2003
Prospective , observation study in private practice setting ASA PS I and II patients for EGD, colonoscopy, liver biopsies Propofol bolused 30‐50 mg and titrated to effect (10‐20 mg boluses)
7 cases of respiratory compromisep y p Mean discharge time: 18 minutes after completion of procedurep
Reported high safety, patient and physician satisfaction
Safety of Endoscopist‐directed f l dPropofol Sedation
T l f 6 6 Total of 646,080 cases 0.1 % required mask ventilation
GastroenterologyOctober 2009
11 intubations 4 deaths
Conclusion: Death rate for EDP is 1 in 161,515 EDP has lower mortality rate when propofol is used compared to BZD and narcotics
Comparable safety rating compare d to GETA(Mortality rate 1 in 10,000 to 1 in 50,000)
Safety of Endoscopist‐directed f l dPropofol Sedation
E iEconomics Estimated cost per life‐year saved to substitute anesthesia specialists was $5 3 millionanesthesia specialists was $5.3 million
Estimated cost per case for anesthesia provider: $298 ‘Back of the Envelope analysis’Back of the Envelope analysis
Assumption all four deaths would have been prevented
Life expectancy (maximum of 85 years) No other deaths occurred
Ref :http://www.youtube.com/watch?v=FGmOxu9L1d4
Role of AnesthesiologistsRole of AnesthesiologistsA ti l I l d Actively Involved
Define “Safety”What is an acceptable rate of adverse events?
Develop Standard Definitions of Adverse EventsDevelop Standard Definitions of Adverse Events Develop Objective Tools to Monitor and Measure the severity and rate of adverse eventsthe severity and rate of adverse events Eliminate self reporting
d h Conduct Research Safety and economicsy
Role of Anesthesiologistsg Leadership role in credentialing providers that
d i i t d d tiadminister deep sedation Educational requirements Participation and oversight in Credentialing, QA and Peer Review Committees
Competency Standards Standard of Care Standard of Care
Role of Anesthesiologists
Educational Responsibilitiesd Advisory capacity
Educational opportunities Medical School Residency Programs Residency Programs Hospital Programs
A i l i h i l Ad i i i Actively engage with Hospital Administration Patient advocacy
5th International Multidisciplinary Societyfor Pediatric Sedation Conferencefor Pediatric Sedation ConferenceMay 23-26, 2010 H tt RHyatt Regency Louisville, KY
www.pedsedation.orgwww.pedsedation.org
Thank you!y
Pediatric Sedation ResearchPediatric Sedation Research Consortium Multi‐disciplinary group of medical professionals dedicated to improve the quality of care to pediatric dedicated to improve the quality of care to pediatric patients receiving sedation
First 0rganized meeting May 2003 First 0rganized meeting May 2003 Development of a web based data collection toolP bli i f di i d i li Publications of pediatric sedation quality assurance issues
Development of PediatricDevelopment of Pediatric Sedation Services AnesthesiologistsI i i Intensivists
Emergency Room Physicians Hospitalists Physicians medically directing RNs (NAPS)
Gastroenterologists Radiologistsg Cardiologists Pediatricians
List of Participating InstitutionsList of Participating Institutions Alfred I Dupont Children's Hospital Avera Mckennan Hospital
C F V ll M di l C
Wilmington, DE Sioux Falls, SD
F ill NC Cape Fear Valley Medical Center Children's Healthcare of Atlanta Egleston Campus Children's Healthcare of Atlanta Scottish Rite
Campus Children's Hospital of Philadelphia
Fayetteville, NC Atlanta, GA
Atlanta, GA
Phil d l hi PA Children's Hospital Omaha Children's Mercy Hospital Chris Evert Childrens Hospital Columbus Children's Hospital Dartmouth Hitchcock Medical Center
Philadelphia, PA Omaha, NE Kansas City, MO Fort Lauderdale, FL Columbus, OHa t out tc coc ed ca Ce te
Denver Children's Hospital DeVos Children's Hospital Eastern Maine Medical Center Gundersen Lutheran Jackson Memorial Hospital University of Miami
Lebanon, NH Denver, CO Grand Rapids, MI Bangor, ME LaCrosse WI Jackson Memorial Hospital, University of Miami
School of Medicine Kosair Children's Hospital, University of Louisville LeBonheur Childrens Medical Center Medical University of South Carolina N Y k U i it S h l f M di i
LaCrosse, WI Miami, FL
Louisville, KY Memphis, TN Charleston SC New York University School of Medicine
Rainbow Babies and Children's Hospital Tod Children's Hospital UMass Memorial Medical Center University of Florida
Charleston, SC New York, NY Cleveland, OH Youngstown, OH Worcester, MA
G i ill FL University of Virginia Yale New Haven Children's Hospital
Gainesville, FL Charlottesville, VA New Haven, CT
